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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803424
Report Date: 10/12/2023
Date Signed: 10/12/2023 03:20:19 PM

Document Has Been Signed on 10/12/2023 03:20 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:PACE FAIRFIELDFACILITY NUMBER:
486803424
ADMINISTRATOR:TERRY ROACHFACILITY TYPE:
775
ADDRESS:350 CHADBOURNE RDTELEPHONE:
(707) 427-1731
CITY:FAIRFIELDSTATE: CAZIP CODE:
94534
CAPACITY: 75CENSUS: 61DATE:
10/12/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:03 PM
MET WITH:Teri Roach, Program DirectorTIME COMPLETED:
03:30 PM
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On 10/12/2023 Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr inspection for this facility and met with Program Director, Terri Roach. The facility is licensed by PACE Solano and currently serves 61 clients, 45 of which were at the facility at the time of visit. The facility is currently conducting partial in-person service program with hybrid options available to some clients. The facility runs on staggered scheduling.

LPA continued with a tour of the facility with Director; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Fire extinguishers were found to be last charged 8/13/2023. Carbon monoxide detector located in hallway connecting all classrooms area was tested and found to be in working order. Alarmtech Security Systems conducted fire safety inspection on 3/7/2023 for all exits, safety devices including sprinklers, alarms and smoke detectors.

Clients were observed to be engaged in various group activities including, discussion, arts & crafts, group movie and other options to choose during classroom hours. Classrooms may also vary depending on client level of care. During the visit, transportation staff and clients had returned from daily outings. Outings include visits to local parks, shopping centers and field trips to local attractions. Facility designates several Direct Support Staff to accompany clients by group and staff to client ratio. Clients observed to have positive relationship with staff continuously engaging and participating with clients. LPA was informed that clients currently provide their own meals with snacks provided throughout the day. Facility also offers scheduled lunch outings scheduled throughout the month. Facility primarily holds outdoor activities during outings and also has a large private outdoor patio located on the side of the building. Toxins, cleaning supplies and other potentially dangerous items are stored in a designated cleaning supply closets throughout the facility secured inaccessible to clients. LPA observed ceiling paneling in the kitchen area in need of replacement due to water damage. The Director has previously repaired a paneling for a similar reason and will be contacting the building maintenance for repairs. Photo corrections of repairs are to be submitted to CCLD once completed. Technical Advisory.

Continue onto LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 10/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/12/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: PACE FAIRFIELD
FACILITY NUMBER: 486803424
VISIT DATE: 10/12/2023
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LPA also conducted a spot mediation check for clients and found all administration and prescription input records to be in order. Medications were located in designated drawers and all found to be secured in staff office. Facility has contracted with R&D Transportation Services. Water temperature at faucets accessible to clients measured between 108.3 and 117.5 degrees F which is within Title 22 regulations requiring water measurements between 105 and 120 degrees F. LPA conducted a file review of client records and found all items including, program individual plans, personal rights and physician's report to be updated or in order. LPA conducted sample file review of staff records and found all staff to have sufficient CPR & 1st Aid training completed. Recently hired staff have also completed all onboard training with certification on file.

LPA requested the following documents be sent to CCL by COB 11/12/2023:

LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Client’s/Resident’s

No deficiencies cited during today's visit.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2023
LIC809 (FAS) - (06/04)
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